Workplace Distress and Ethical Dilemmas in Neuroscience Nursing

Marit Silén; Ping Fen Tang; Barbro Wadensten; Gerd Ahlström


J Neurosci Nurs. 2008;40(4):222-231. 

In This Article


All 21 nurses interviewed experienced ethical dilemmas and distress in their job to some extent ( Table 2 ). In keeping with the aim of this study, the results are grouped according to the themes of the four content areas: workplace distress, ethical dilemmas, managing distress and ethical dilemmas, and quality of nursing.

Notwithstanding the focus on distress and ethical dilemmas, a majority of the nurses (16 out of 21) also expressed satisfaction with components of their working situation. They liked their jobs and thought that neurology was an exciting field in which to work, and they could see how the patients' medical treatment benefited from developments in the field. There was a positive spirit of camaraderie that was important with regard to coping with the demanding working situation. The communication among the nurses was good, and they supported each other. The work was seen as meaningful, especially when patients recovered and made progress.

Demanding and Stressful Working Situation in Conjunction With Lack of Influence. The nurses described their working situation as physically and mentally demanding. Many of the patients were seriously ill and needed substantial care. The nurses felt that there was insufficient nursing staff in proportion to the patients' care needs and that the workload was too heavy. The consequences of the heavy workload were fatigue during leisure time, exhaustion, and frustration.

I mean, when patients come to the neurology department, they can have symptoms ranging from vertigo to total hemiparesis and aphasia. And if we've got 20 patients like that, and there are just four or five of us on duty one evening, of course you haven't got the time to do as much as you'd like to. It's been very hard going for a long time now, which has led to frustration. You can see it by looking at the staff: Everybody's tired—it's a burden physically and mentally. And it causes conflicts, that's plain to see. (Nurse 3)

The nurses felt they could not do their job properly and felt inadequate because they made heavy demands on themselves. Those with limited experience as nurses felt a great deal of tension when they started, and they regretted not having been given an adequate introduction to their new workplace. The stressful working situation had the result, as the nurses saw it, that they constantly had to change their prioritization of the work.

The demands made on them by relatives of the patients were felt to have increased. Relatives would insist on speaking to the physician immediately and did not accept waiting. These sometimes unrealistic demands and dissatisfaction were hard to handle and resulted in sadness and frustration among the nurses interviewed. Another source of stress was the administrative work, which was viewed as burdensome. In particular, planning for the patients' aftercare resulted in increased administrative work and less time spent with the patients. This time allocation was experienced as negative.

The physical working environment was perceived as lacking patient wards that were spacious enough for both patient care and the needs of visiting families. Also, the mental environment was experienced as stressful. This was mainly the result of the impending reorganization and merger of some departments, including their own. This created a lot of uncertainty and required a great deal of energy. The nurses also expressed dissatisfaction with the salary and the new work schedule. They felt that they could not influence their working situation—they could not, for example, influence either the fact that there was a shortage of nursing staff on a certain shift or the frequent reorganizations and demands for spending cuts. There were routines, political decisions, and economic factors that they felt hindered them from working the way they wanted.

Lack of Communication and Cooperation With Other Healthcare Team Members. The nurses felt that they were not appreciated by the physicians and not respected as professionals. Their knowledge about the patients was not seen as valuable, and their suggestions were not welcomed by all of the physicians.

Usually it's this way: I'd say, you think that as a nurse, you know the patients well, but then the physicians don't want to hear what you've got to say. And I find that pretty frustrating sometimes. (Nurse 1)

The nurses did not always have the information they needed from the physicians and had to ask for it. In addition, the lack of cooperation and communication was thought to result from a hierarchical structure in which physicians had more power and influence than the nurses. According to the nurses, the cooperation and communication with other members of the nursing staff did not always function satisfactorily. There was a lack of understanding of the nurses' responsibilities on the part of the assistant nurses, especially when the workload was heavy. The assistant nurses wanted the nurses to help them in the essential care, but the nurses often had medical tasks to perform, and this could result in conflicts. Conflicts also arose between nurses, for example, when it was perceived that not everyone took enough individual responsibility for her or his work, and between nurses and physicians when the nurses thought that the physicians were not treating the patients or families respectfully.

Disagreeing with colleagues made the nurses sad. In difficult situations the nurses had experienced a lack of support from other members of the nursing staff and from the clinic management. Cooperation and communication with the staff in the public community care about the patients' aftercare was described as dysfunctional and difficult. The nurses did not feel that they could influence decisions, nor did they perceive that their views were seen as useful and important.

Difficulty Witnessing the Situation of Seriously Ill Patients. When the patients were young and seriously ill, often because of a brain tumor, the nurses felt sad. They felt sympathy for these patients. Sometimes the patients were close in age to the nurses, and then their condition affected the nurses even more; they felt helpless. If these patients had small children, the nurses felt that it was especially unfair that they should be stricken with illness because they had their whole lives before them. It could be hard to stop thinking of the patients after work, and the nurses wondered what the future held for those whose prognosis was uncertain. It was very mentally demanding to take care of these patients.

We've got a lot of people lying here dying, old and young. We've had patients with brain tumors, for example, who've been of our own age—it's very easy to relate to them. There's a lot of tragedy around you, it's so saddening. (Nurse 7)

Troublesome Decision Making on Initiation or Withdrawal of Treatment. Dilemmas often concerned initiating or withdrawing a certain treatment, and it was felt that each decision was unique.

Well, the classic case, I must say, is when a patient comes in and is in a bad way and can't eat. Do you give no treatment, or do you put the patient on a drip and use a probe and all that? I think that's dreadfully difficult. (Nurse 8)

The dilemma was, as the nurses saw it, whether the patient would benefit from the treatment or if the treatment would cause pain or prolong suffering. The nurses believed that treatment should not be initiated or continued just because it was possible. The price the patient had to pay could be too high, and the patient's quality of life had to be considered. The decision-making process was experienced as difficult, and the nurses felt powerless, for example, when withholding fluid from a patient who could not swallow or when explaining to the family that the patient's infusions would be discontinued. One distressing situation involved withdrawing life-sustaining treatment, but the patient continued to live. Distress was also involved in caring for a patient where no decision about continued treatment or withdrawal of treatment had been made. The lack of a decision, or an incomprehensible shift between active treatment and no treatment at all, was emotionally difficult to bear. The decision making was perceived to be influenced by a number of factors, such as the physician responsible and the age of the patient. The diagnosis was also a determining factor when deciding about life-sustaining treatment, because it was felt that patients with certain diagnoses received much more treatment than patients with other diagnoses.

Conflicting Views on Right Treatment and Decision. Nurses and physicians sometimes held different opinions concerning the right treatment or decision for the patient. When the physician had decided on further treatment, but the nurse thought that the treatment should be terminated, the nurse was frustrated and angry at having to examine and treat a patient who was dying. However, sometimes the nurses thought that the physicians' decisions to terminate treatment were too rash.

Sometimes there have been patients that you've thought were a bit too alert perhaps—yes, a bit too alert, perhaps, for you to discontinue the drip. (Nurse 16)

It was very difficult to nurse a patient who was conscious, but the treatment had been terminated. The physicians did not always include the nurses in the decision making, and the lack of cooperation negatively affected patient care. The family and the nurses could have conflicting views on treatment and decisions, and there arose a dilemma concerning whether the decision should be made in accordance with the relatives' views or those of the nurses. It could be difficult to resolve such a dilemma because the nurses lacked time and knowledge and because of the physicians' attitudes.

Difficulties in Providing for Patients' and Families' Needs, Rights, and Desires. The nurses indicated that it was difficult to maintain the patient's integrity. This was the case, given that many of the patients had to share a room, and sometimes they had to be placed in the corridor. At such times it was almost impossible to talk privately to the patient.

Well, when it comes to patients' integrity, we've got a lot of rooms with two beds and just a curtain between. You wash and you dry, and there's just a curtain between. The other patient's on the other side of the curtain and can take in what you're saying—and they hear everything. If you're doing the rounds, and the other patient's on the other side, there's a lot you take up that you know you yourself wouldn't want taken up under any circumstances if somebody else was listening—very private things. (Nurse 11)

Integrity was also threatened when the nurse had to persuade the patient to accept a new living arrangement. The municipality could not always afford a living arrangement that would be the best for the patient, and the aftercare was thus not directed by the patient's need. During the coordinated-care-planning meetings, where care staff and the social welfare case officer discussed the aftercare of the patient, there could be a problem because the patient was not included in the discussion. Thus the patient did not play a part in the decision making regarding his or her own care. There was a dilemma when the patient was in too poor a state of health to participate or was too shy to do so. The nurses had an ambivalent view of family participation. On one hand, nurses wanted families to be more involved in the decision making concerning the care of the patient; on the other hand, the families might have too much influence, and the patient's care would be provided on their terms.

Accepting and Adjusting to the Situation in an Active Way. The nurses accepted the decision about the care of the patient made by the physician or social welfare case officer, but they did not always agree with it. They also accepted the fact that people are of different opinions, and therefore they tried to compromise. They could express their opinions even when they knew that it would not change the decision because they felt it was important to make their own opinions clear as a means of accepting the decision.

You take it up with the physician doing the rounds, for instance. Should that patient have a drip, or not? I try to pass on what the family thinks. But then you adapt to what the physician prescribes, to what gets decided. And then you hide behind that, really: It's a prescription, I do what the physician says, and then I stop thinking about it. Or: I've got my own opinion, but I accept it. Then you sort of just move on. (Nurse 17)

Some of the nurses accepted that it was difficult to influence the decisions and the way of working, and they decided to adjust to that fact and the norms of the group on the ward. Others adjusted to the situation by trying to take control over it, for example, by using the time in the most effective way. They planned and prioritized their work and sought to share their time fairly among their patients, thus giving equal attention to the quiet patients.

Seeking Support From Colleagues. It was of great value to have the opportunity to talk to colleagues about ethically difficult situations. These conversations could take place during coffee breaks or when reporting to the next shift, but a more formal meeting could be organized when there was a situation that involved the whole staff. The nurses related that the informal discussions involved the nurses and sometimes the physician, while the discussions planned beforehand included the nurses, the physician, and, when necessary, the medical social worker. Both nurses and physicians could initiate these discussions. The subject of discussion was often decisions about life-sustaining treatment. Sometimes the discussions took place before the physician made his or her decision in order to throw light upon as many aspects of the situation as possible. At other times the decision had already been made, but the nursing staff felt that they did not agree with the decision, and therefore they initiated a discussion with the physician to better understand the reasons for the decision.

I think we often make good decisions, I really do. If I don't agree about this or that, or someone else doesn't, we talk it through. The physician usually takes part, and then there are the nurses and assistant nurses taking care of the patient, and you've got a chance to say all that's on your mind and in the end feel it's a joint decision and the best one. (Nurse 20)

Hearing the reasons for the decision helped the nurses to move on and could also result in a reconsideration of their own attitudes. They wished there was a forum, for example, ethics rounds, to discuss difficult situations together.

Striving for New Strength in Private Life. Not taking home thoughts about work and patients was another way to manage distress. This had been difficult when nurses were just starting out, but it had become easier with increased working experience. It was important not to let work influence your private life, but sometimes it was hard to let go. Often, the nurses talked about their work stressors to family or friends. It could be particularly helpful to talk to family members or friends who were nurses themselves because they were likely to have a better understanding of the situation, but sometimes it was a relief to talk to someone not involved in nursing.

I usually talk to my family about it. It can be pretty nice for the very reason that they're not involved as I am. (Nurse 9)

Off-duty time provided the nurses an opportunity to renew their strength and keep work in proportion by taking care of themselves. An example offered was going for walks to clarify their thoughts.

Reflective Thinking and Previous Experiences. In stressful situations, when there was a heavy workload, the nurses tried to identify their own limitations. They did their best, and at the same time did not see themselves as irreplaceable, trusting that the nurses working the next shift could carry on with the tasks they had not managed to finish.

You try and do your best when you're there, and then sometimes when you've been on the evening shift, you wake up in the night and think: Did I do that? But then you've got to say to yourself: OK, but there's somebody else there now, and they can think as well. I mean, you've got to learn to look at it that way. After all, nobody's perfect, are they? (Nurse 19)

The nurses also recognized their own limitations when they directed the patient or family to another member of staff. For example, they consulted the medical social worker when they thought that they were not the best suited to handle particular situations. In difficult situations they used every available means to do their best for the patients, and then they would be satisfied with their own work, even if the situation did not have the outcome they desired. Another strategy used by the nurses was to look upon the situation from another person's point of view to shed new light on it. When the situation involved decision making with regard to life-sustaining treatment, it could be helpful to have a holistic view of the patient to understand the physician's decision and to give full weight to the patient's human dignity. More experience as a neuroscience nurse reduced distress and increased confidence in handling different kinds of situations, and it had also made it easier to prioritize. Working experience also enabled the nurse to reflect on ethically difficult situations from different perspectives.

Satisfaction With Nursing Quality and the Individualized Care. The quality of nursing care was judged as being high by a large majority of the nurses. They thought they were able to maintain high quality even though sometimes there were not enough nurses, which ultimately did have negative consequences for them. Factors that contributed to high-quality care were well-qualified nurses with specialized knowledge about neurological diseases, a holistic view of the patient and his or her situation, and teamwork with other groups of healthcare providers.

The care's very good here. All the problems are carefully considered. There's nutrition, and there's the problem of pain, and—well, just everything, you might say. Right from the start, I could see that the whole person was cared for here. (Nurse 4)

The nursing staff often received appreciation from families and patients who were satisfied with the care, even though the nurses felt that they had not done much. The satisfaction of families and patients has also been shown in opinion polls, where nurses received good ratings for the care they provided. The care of the patient was individualized as much as possible—each patient, for example, had his or her own training program during rehabilitation. The nurses also took measures to increase the participation of patients in their own care through information and in conjunction with decision making at coordinated care planning meetings. Nurses left the room to allow the patient to take a more active part in the decision making during such a meeting. The high quality of nursing care was also evident in the kind treatment of the families, which was considered an important part of good care. The relatives received individualized information about the patient's condition, and the nurses lent a sensitive ear to the family's desires. When the family participated in decision making with regard to the patient's care, the nurses supported them.

Lack of Nurses and Time Hinders Stable and High Nursing Quality. Although there was a general satisfaction with the nursing quality, there was room for improvement. The quality was thought to be dependent on the workload and the number of nursing staff working. This meant that the quality was thought to be unsatisfactory when the workload was too heavy or there were too few nurses, which could be the case on evening shifts and on weekends. On these occasions, the nurses felt that they could not provide for all patients' needs, and that scarce resources hindered recovery and rehabilitation. Nurses felt that they did not have time to properly talk to the patients and could not always give them the basic care, despite the fact that the patients were experiencing life-threatening or life-changing diagnoses and needed to share their feelings with the nurses. Nor was there time to do something special, for example, go for a walk with the patient. The nurses' time for answering the families' questions was limited and caused them dissatisfaction.

What I miss from the past is that you used to be able to go for a walk with the patient, do crosswords together. Or you could sit and read to the patient, or sit and talk. There's none of that anymore. I'd like to have it back, that quality. (Nurse 5)

Changing working conditions, such as new work schedules, and the future reorganization of the clinic, were other factors cited by the nurses as causing a decline in the quality of nursing and an interruption to the continuity of care. In conjunction with the reorganization, some of the nurses with specialized knowledge would be transferred to another clinic, and they were concerned that this would negatively affect the quality of nursing care.


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